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http://psycheducation.org/primary-care-provider-resource-center/behavioral-activation-therapy/

Behavioral Activation Therapy

[printable version of the text below, might be easier to read and follow:  Behavioral Activation Therapy]

Here’s a version of BAT, to accompany a more formal Manual. The instructions below are simplified because our patients’ difficulties are usually complex and their “self-efficacy” (ability to change their own behavior, and belief in that ability) is often very low.  They’ll usually need to start simple and small.

Page and pdf numbers below refer to the Manual found at http://web.utk.edu/~dhopko/BATDmanual.pdf   . When you’ve read the following simplified guide, then read the Manual from Unit 5 (page 266; pdf page 12) to the end, including the Appendices. You’ll see it’s considerably more complicated than the version here. Some of your clients may be able to handle some parts of the more complex version.  Knowing both versions will give you a better understanding of the method.  One more simple version is described in a 30-minute video:  http://impact-uw.org/training/onlinetraining.html , very worth it (including an important, amusing comment by Dr. Unutzer at minute 21).

First, a simple approach:

A.  Get at least some buy-in for treatment.   E.g.  after listening well to their struggles, try something like: “You have some really serious problems. You’ve been struggling for a long time.  It probably seems overwhelming, the idea of even trying to change the way things are. Your mood/anxiety problems have made it difficult to do much of anything, especially things that you might get some real enjoyment from.  But if you want to give it a try, I’ll work hard to help you, and we’ll make the steps really small, at least at first.”

If she is not ready (this should be apparent very early) shift gears to Motivational Interviewing* mode: elicit the story of the struggle slowly and well, and listen for the wish for things to be different, reinforcing that. Stay in listening mode until there’s room to “hand back the bouquet” of reasons for change that you heard.

B.  Once you have a willing client, move through the following steps at her pace. Some clients will go fast, some will go very slowly, e.g. one of the steps below per week or even slower. The key is to have success early; you can go faster/farther later.  Keep a file for each client with copies of their worksheets. Give them a folder in which to keep their copy.  If they “fail” a step, consider that your mistake: you didn’t make the plan clear enough, small enough, or get full agreement – something like that. This takes pressure off the client who’ll easily regard not following through as his own personal moral failure.

Step 1:   Make a list of activities you’d like to pursue. We’re looking for 10-15 of them. Brainstorm first; rank-ordering comes later.  Worksheets: Appendix A in the manual (page 280, pdf page 26); or if you need an even simpler breakdown, with even more choices,  consider this list of pleasurable activities:   http://elishagoldstein.com/assets/183-pleasurable-activities-to-choose-from.pdf

Step 2: Rank the 10-15 activities from Step 1 by difficulty. Worksheets:  Activity Ranking Sheet, page 270 (pdf page 16); or http://psychology.tools/activity-selection.html

Step 3:  Starting with the easiest on that list: is it too easy — will this be a challenge at all? Or is it too hard – how likely is it that she will be able to actually get this done, in the coming week?  E.g. rate how likely on a scale of 1-10 where 0 is “no way” and 10 is “positive”. She needs to rank it 7 or higher. If even the simplest behavior is not likely to happen, then break that behavior down into smaller pieces. Find a simple step where she begins to be almost offended: “sure, I can do that.” Start there or one step higher.

Step 4:  Make a plan for him to actually do this behavior in the coming week.  When and where will it happen? What day, what time of day?  If he’s ready for more than just the one behavior, consider a second, and at most a third behavior.  Use the BAT Initial Activity Planning Sheet  to determine what day(s), what times of day the behavior will occur.  Ask:  “what’s going to get in the way of this actually happening?” and brainstorm work-arounds for barriers.

Step 5:  Return visit, or f/u phone call. How did the plan go? What got in the way? “Failure” is therapist’s error for not structuring activity properly; just need to return to plan and break it down smaller, or brainstorm other routes around barriers.

If “success”, next step:  use the Initial Activity Planning Sheet and add additional activities, moving up their Activity Ranking Sheet. Go slowly enough to make sure of “success” again.  Reinforce continuing the first successful behavior.

Step 6:  Make a plan to continue multiple activities. Use the Task Planning and Achievement Record http://www.self-help.tools/assets/worksheets/Task_Planning_And_Achievement_Record.pdf  (which is less complicated than but analogous to Figures 7 and 8 in the Manual).

Charting Progress

By week 2, certainly by week 3, if client is successfully underway, create an Activity Level Graph (pg 277, pdf page 23, Figure 10).  Also obtain PHQ-9 and GAD-7 scores at least every other week and enter in EPIC Documentation Flowsheet.

 

 

*Motivational Interviewing review:

http://integratedcare-nw.org/webinars/motivinterview_050610.html

Slides for that webinar:     http://uwaims.org/files/slides/Dunn-MotivInterv-Slides.pdf

Treating the Mood Spectrum

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